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Network Participation Overview

Network Participation - Practitioners

To initiate the credentialing process, West Virginia physicians and allied health practitioners must complete the most recent version the State of West Virginia Uniform Credentialing Form (application) or may enter information into the Council for Affordable Healthcare's ("CAQH") database, as long as it is printed on the mandated West Virginia uniform credentialing form (application).

Highmark West Virginia is not permitted to accept the CAQH application forms by law. The most recent version of the West Virginia uniform credentialing and re-credentialing forms are available on the West Virginia Insurance Commissioner's website at www.wvinsurance.gov.

Network Participation - Facility and Organizational Providers

When the contracting process is initiated, Highmark West Virginia will send an application, if applicable, and/or a letter detailing the types of credentialing information the provider must submit.

Facility and organizational providers are to submit requested credentialing documentation to West Virginia Family Health's (WVFH) Network Quality and Credentialing Area.

Member Enrollment Process

Under the West Virginia Mountain Health Trust Program the State determines eligibility and enrollment through Automated Health Systems, a broker hired by the State of West Virginia for enrollment services. Once the member selects WVFH, the plan is notified electronically of enrollment. At that time, a packet of information is sent to the member along with their WVFH identification card.

Determining Member Eligibility

A WVFH member will have (2) cards: a WVFH ID card, as well as a West Virginia Medicaid card. Because of frequent changes in a member's eligibility, each participating practitioner is responsible to verify a member's eligibility with WVFH before providing services. Verifying a member's eligibility along with the applicable referral or authorization will assure proper reimbursement for services.

To verify a member's eligibility, the following methods are available to all practitioners:

  • WVFH Identification Card - the card itself does NOT guarantee that a person is currently enrolled in WVFH. Members are only issued an ID Card once upon enrollment, unless the member changes their PCP or requests a new card. Members are NOT required to return their identification cards when they are no longer eligible for WVFH.
  • The WVFH IVR System- This telephonic system is available 24 hours a day, 7 days a week at (1-888-907-8002).

Member ID Card

Subject to BMS approval, the ID card will appear as follows:

West Viriginia Family Health sample Member ID card - front

West Viriginia Family Health sample Member ID card - back

West Viriginia Family Health sample Member ID card - front

West Viriginia Family Health sample Member ID card - back

Processing PCP Change Requests

When a member wishes to change his or her PCP, the change is processed as follows:

  • When the request is received prior to the 25th of the current month, the new effective date will be the first of the following month. For example: a member's request is received on October 7th, the member will be effective November 1st with the new PCP.
  • When the request is received on or after the 25th of the current month, the new effective date will be the first of the subsequent month. For example: a member's request is received on October 28th, the member will be effective December 1st with the new PCP. If the member requests to change his or her PCP immediately, an exception to the above guidelines can be made if the situation warrants.

Inpatient Admissions

In order for WVFH to monitor the quality of care and utilization of services by our members, all WVFH practitioners are required to obtain an authorization number for all hospital admissions and certain outpatient surgical procedures by contacting West Virginia Family Health's Utilization Management Department at 1-855-412-8003.

WVFH will accept the PCP, ordering practitioner, or the attending practitioner's request for an authorization of non-emergency hospital care; however, no party should assume the other has obtained authorization. WVFH will also accept a call from the hospital's Utilization Review Department.

The Utilization Management Representative refers to the WVFH Medical Director if criteria or established guidelines are not met for medical necessity. The ordering practitioner is offered a peer review opportunity with the WVFH Medical Director for all potential denial determinations.

Referrals and Authorizations General Information

Referrals and authorizations are necessary in order to preserve the PCP's Gatekeeper relationship with the patient. Both processes allow WVFH to manage the care of its member population. The major differences between referrals and authorizations are:

  • Referrals allow the PCP to approve specialty services for members on their panel.
  • Authorizations allow WVFH to confirm eligibility of the member prior to receiving services, to assess the medical necessity and appropriateness of care, to establish the appropriate site for care, and to identify those members who would benefit from care management.
  • Some services, such as hospital admissions, require authorization by the WVFH Utilization Management Department. To authorize a service, please call West Virginia Family Health's Utilization Management Department at 1-855-412-8003.

In certain instances, members do not require a referral from the PCP to see a participating specialty care practitioner.

For the following services, members can self-refer:

  • OB/GYN Services
  • Family Planning Services (do not have to be rendered by a participating provider)
  • Mental health/substance abuse services
  • Chiropractic services (authorization must be obtained by the chiropractic office, including the initial evaluation)

Referrals

When a PCP determines that a member requires medical services or treatment outside of the PCP's office, the PCP must issue a referral to a participating facility or specialty care practitioner. If services are performed in a hospital setting, the referral should be issued to the hospital's provider identification number. PCPs may not issue referrals to other PCPs.

Authorizations

Authorization is the responsibility of the admitting practitioner or ordering provider and can be obtained by calling West Virginia Family Health's Utilization Management Department at 1-855-412-8003.

If a service requires authorization and is being requested by a participating specialist, the specialist's office must call WVFH to authorize the service.

Hospitals may verify authorization by calling the WVFH Utilization Management Department.

Physical, occupational or speech therapy requires authorization by the ordering practitioner or the PCP.

The following information is needed to authorize a service. Please have this information available before placing a call to the Utilization Management Department:

  • Member name
  • Member's 8-digit WVFH ID number
  • Diagnosis (ICD-9 Code or precise terminology)
  • Procedure code (CPT-4, HCPCS, or MA Coding) or billing codes for durable medical equipment requests
  • Treatment plan
  • Date of service
  • Name of admitting or treating practitioner
  • Name of the practitioner or provider requesting the treatment
  • Provider of service NPI number
  • History of the current illness and treatments
  • Any other pertinent clinical information

Pharmacy Services

WVFH allows access to all non-formulary drugs.

If changing to a formulary medication is not medically advisable for a member, a practitioner must fax the Request for Nonformulary Drug Coverage Form, to 1-800-412-8005 during normal business hours. Practitioners should assure that all information on the form is available when calling.

Electronic Claims Submission

WVFH can accept claims electronically through Emdeon. WVFH encourages practitioners to take advantage of our electronic claims processing capabilities.

Submitting claims electronically offers the following benefits:

  • Faster claims submission and processing
  • Reduced paperwork
  • Increased claims accuracy
  • Time and cost savings

For submission of professional or institutional electronic claims for West Virginia Family Health, please use Emdeon Electronic Claims Submission Payer ID — 45276

In addition to edits that may be received from Emdeon, WVFH has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted to Emdeon, but if the codes are not currently valid they will be rejected by West Virginia Family Health. Practitioners must be diligent in reviewing all acceptance and rejection reports to identify claims that may not have successfully been accepted by Emdeon and West Virginia Family Health. Edits applied when claims are received by WVFH will appear on an EDI Report within the initial acceptance report or Claims Acknowledgment Report.

Medical Claims Review

Claims rejected for services that did not have medical records attached or the appropriate referrals or authorizations are subject to a Medical Management Review. All claim records should be sent to West Virginia Family Health. When submitting a written request for a claim review, please provide:

  • A copy of the WVFH Remittance Advice
  • The member's name and WVFH Identification Number
  • The reason the review is requested and include as much supporting documentation as possible to allow for a complete and comprehensive review
  • Date(s) of service in question
  • A copy of the medical record for the service(s) in question (if applicable)

In the event that the claim cannot be reprocessed administratively, a medical necessity review is undertaken. The records will be reviewed by a Medical Review Nurse. If the medical review nurse cannot approve the services, a WVFH Medical Director makes the final decision to approve or deny the claim. A final decision is made within 30 days from receipt of the inquiry.

Coordination of Benefits (COB)

Some WVFH recipients have other insurance coverage. WVFH may not delay or deny payment of claims unless the probable existence of third party liability is established at the time the claim is submitted. Note: WVFH will process and pay EPSDT and prenatal visits as primary even when our records indicate WVFH is secondary and a primary plan exists for the member.

If an explanation of benefits (EOB) is attached to the EPSDT or prenatal claim then coordination of benefits will be applied. We will continue to coordinate benefits and require the primary explanation of benefits when submitting the delivery claim.

In order to receive payment for services provided to members with other insurance coverage, the practitioner must first bill the member's primary insurance carrier using the standard procedures required by the carrier. Upon receipt of the primary insurance carrier's EOB, the practitioner should submit a claim to WVFH.

Appeals, Complaints and Grievances Provider Appeals

Any provider may file a formal provider appeal to request the review of any post-service denial. This process is intended to afford providers with the opportunity to address issues regarding payment only. Appeals for services that have not yet been provided must follow the member Grievance or Complaint processes. The formal Provider Appeal Process must be initiated by the provider through a written request for an appeal. The written request for an appeal, along with all supporting documentation, must be received by WVFH within ninety (90) calendar days of the date of the denial notice.

All written appeals must be sent to:

WVFH – Provider Appeals
P.O. Box 22190
Pittsburgh, PA 15222

Complex Case Management

West Virginia Family Health provides a Complex Case Management program for eligible members A Care Manager can help your patient to better understand their health conditions and benefits and can also help to coordinate health care services by interacting with providers. A Care Manager can tell your patient about community organizations and resources that may meet their needs.

Eligible members may include:

  • Members with multiple medical conditions
  • Members with a complex medical history
  • Members that need assistance to become more self-reliant in managing their health care

To make a referral, please call: 1-855-412-8004, option 2

Participation in this program is voluntary.

West Virginia Family Health will review the request for enrollment and make the final decision for inclusion in the program.